Provider Demographics
NPI:1932756095
Name:RUSIECKI, KIM
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:RUSIECKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 PARLIAMENT DRIVE EAST
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463
Mailing Address - Country:US
Mailing Address - Phone:312-415-7748
Mailing Address - Fax:
Practice Address - Street 1:25 PARLIAMENT DRIVE EAST
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463
Practice Address - Country:US
Practice Address - Phone:312-415-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider